1. Potera, Carol


A new look at guidelines on vaginal birth after cesarean section.


Article Content

An independent panel convened by the National Institutes of Health ( has concluded that vaginal birth after cesarean (VBAC) is an acceptable option for many women who previously had a cesarean delivery. The panel also suggested a reevaluation of current VBAC guidelines and malpractice concerns that prompt repeated cesarean deliveries.


After peaking at 28% in 1996, rates of VBAC deliveries in the United States gradually shrank to below 10% in 2007. Meanwhile, the rates of cesarean deliveries rose markedly, from 21% in 1996 to 33% in 2007-a record rate that accounted for nearly 1.4 million births, according to a recent report from the Centers for Disease Control and Prevention (


It's often claimed that labor after cesarean delivery increases the risk of uterine rupture, as a result of weakness in the uterine wall caused by the incision, and threatens the mother's fertility and the baby's life. Yet the best available scientific data analyzed by the panel showed that fewer than 1% of women who have a VBAC delivery experience uterine rupture; moreover, about 70% of women who have cesareans are still good candidates for normal delivery, and 60% to 80% who attempt vaginal birth succeed. In fact, maternal death is rarer in women who experience labor, regardless of whether they end up delivering vaginally or by cesarean.


"The risks of uterine rupture have been really pumped up," says panel member Tekoa King, a certified nurse midwife; associate clinical professor at the University of California, San Francisco; and deputy editor of the Journal of Midwifery and Women's Health. By knowing that the risk of uterine rupture is extremely low, she says, nurses can push for women to have access to a VBAC.


Despite such reassuring information, pregnant women with a previous history of cesarean section may have trouble finding clinicians and hospitals that allow them to attempt vaginal delivery. According to the report, surveys find that since 1996, about one-third of hospitals and half of physicians no longer offer the choice of labor to women with a prior cesarean delivery, in part because of guidelines from the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) that require surgical and anesthesia teams to be "immediately available" during labor for women with a history of cesarean delivery. Some hospitals simply ban VBAC, either because they can't provide the appropriate emergency team or to avoid litigation resulting from complications of an attempted vaginal delivery.


"The VBAC ban causes women to go to out-of-hospital birth centers or have home births. This could be really dangerous if a woman has a uterine rupture or other complications," says King.


The expert panel urged ACOG and the ASA to "reassess this requirement relative to other obstetrical complications of comparable risk . . . and in light of limited physician and nursing resources" and called for research to better understand the medical and nonmedical factors that inspire or hinder the decision to try VBAC.-Carol Potera